1986. (Office of Vital Records and Public Health Statistics, South Carolina Department of Health and Environmental Control, Columbia, SC.) Clearly the changes in neonatal mortality rates are not explained by changes in birthweight distributions. Low birthweight is an underlying contributor to neonatal mortality intricately related to a host of other biological, medical, sociodemographic, and behavioral factors. While many of these factors are vague, non-specific and non-operational, they are, in turn, related to specific, intervenable factors of prenatal care, nutritional intake, and smoking and alcohol consumption during pregnancy.6 The explanation for the apparent paradox between significant declines in neonatal mortality rates and very marginal improvement in birthweight is not likely to be found in an examination of medical records and routinely collected vital statistics. Finally, the absence of improvement in the proportion of low birthweight (LBW) infants over the time period 1975-86 should raise questions about either a flawed strategy of national health policy and/or inadequate application or utilization of support programs such as WIC (Women, Infants and Children supplemental feeding program), AFDC (Aid for Families with Dependent Children), and food stamps. Focusing on infant mortality as both a guide to operations and as a criterion for success in maternal and infant health programs is a suspect strategy. The effect of reducing the

proportion of infants in the low birthweight tail of the distribution would certainly result in improvements in infant mortality rates, but not vice-versa. If the evidence of improvement among those whose infants weighing above the 2500g critical value is correctly interpreted, then there is more than a hint that the national strategy as it is applied in South Carolina should look beyond infant mortality. One approach would be to renew attention to conditions of life which are clearly known to influence maternal/familial wellbeing: hygiene, sanitation, crowding, nutrition, injury hazards, toxic substances, and unsafe conventions of behavior in the home and neighborhood. REFERENCES 1. McCormick MC: The contribution of low birth weight to infant mortality and childhood morbidity. N Engl J Med 1985; 312:82-85. 2. IOM Committee to Study the Prevention of Low Birthweight: The significance of low birthweight. In: Institute of Medicine: Preventing Low Birthweight. Washington, DC: Academy Press, 1985; 21-45. 3. Kleinman JC, Kessel SS: Racial differences in low birthweight-trends and risk factors. N Engl J Med 1987; 317:749-753. 4. National Center for Health Statistics: Health, United States, 1985. DHHS Pub. No (PHS) 86-1232. Washington, DC: Govt Printing Office, 1985; 66. 5. Daniel WW: Biostatistics: A Foundation for Analysis in the Health Sciences. 4th Ed. New York: John Wiley and Sons, 1987; 583-636. 6. US Department of Health and Human Services: Report of the Secretary's Task Force on Black and Minority Health. Vol. VI: Infant Mortality and Low Birthweight. Washington, DC: Govt Printing Office, 1985; 35-85.

Unlicensed Midwifery Practice in Washington State SUSAN J. MYERS, LM, MPH, PATRICIA A. ST. CLAIR, ScD, STEPHEN S. GLOYD, MD, MPH, PHILIP SALZBERG, PHD, AND JOANNE MYERS-CIECKO Abstract: We examined the role of unlicensed midwives in Washington State by questioning mothers of infants born outof-hospital with an unlicensed person in attendance. Only a small proportion of the state's births (0.11 percent) were attended by unlicensed midwives. Unlicensed midwives attended 7 percent of home births, licensed midwives and certified nurse-midwives attended 69 percent. Mothers chose unlicensed midwives because they had religious beliefs in common, or because they were the only providers available who would attend a home birth. (Am J Public Health 1990; 80:726-728.)

Introduction In 1981, the Washington State legislature passed a Midwifery Act which established standards for direct-entry (i.e., without prior nursing) midwifery education and practice. To become a licensed (direct-entry) midwife, the law Address reprint requests to Susan J. Myers, LM, MPH, Seattle Midwifery School, 2524 16th Avenue South, Seattle, WA 98144. Ms. Myers is also with the Department of Health Services, University of Washington, which is also the affiliation of Dr. St. Clair and Dr. Gloyd. Dr. Salzberg is with Washington State Department of Licensing. Ms. Myers-Ciecko is with the Seattle Midwifery School. This paper, submitted to the Journal February 8, 1989, was revised and accepted for publication October 27, 1989. © 1990 American Journal of Public Health 0090-0036/90$1.50


specifies that applicants be graduates of a state accredited educational program wherein they receive at least three years of coursework and clinical experience. Only a handful of other states license direct-entry midwives. Washington's law is considered unique in the United States because its standards are consistent with those established by the International Confederation of Gynecology and Obstetrics and the International Confederation of Midwives.' The Washington State Midwifery Act permits unlicensed midwives to practice as long as no fees are charged. In a recent review of the Act, the legislature added an amendment to allow unlicensed midwives with documented experience to challenge the licensing examination without completing the required coursework. The amended Act also stipulated that data be provided to determine the role of unlicensed practitioners in the provision of maternity services in the State of Washington. Accordingly, the present study was undertaken to determine the proportion of births that were attended by unlicensed midwives and other unlicensed attendants, and the reasons for mothers' choice of an unlicensed midwife.

Methods Births which took place out-of-hospital (in a birth center, medical facility, home, or "other" setting) were selected from 1986 birth certificates (N = 1656). Those with an unlicensed person in attendance (mother, father, unlicensed midwife, other or unknown attendant) were identified (N = 423). Records AJPH June 1990, Vol. 80, No. 6

PUBLIC HEALTH BRIEFS TABLE 1-Birth Attendant Reported by Respondents Compared with Birth Attendant Recorded on Birth Certficate

TABLE 3-Soclodemographic Characteristics of Mothers Who Gave Birth at Home By Attendant Type Washington State, 1986

Birth Attendant Reported by Respondents Birth Attendant Recorded on Birth Certificate

Birth Attendant Types

Licensed Midwife/ Certified Father Unlicensed Physician Nurse-Midwife Mother Midwife Other Total

Father/Mother Unlicensed Midwife Other/Unknown Total

0 1 23 24

17 12 38 67

26 0 15 41

7 9 11 27

0 0 47 47

50 22 134 206

were checked by matching attendant's name on the birth certificate against state rosters of licensed providers. Eight births were excluded because of a missing address or because the birth mother was not the infant's legal guardian. A questionnaire was mailed to the remaining 415 mothers, asking for verification of type of birth attendant and place of birth, whether they had planned an out-of-hospital birth, and the reasons for their choice of birth attendant. Follow-up telephone calls were made to non-respondents for whom telephone numbers could be found. A second questionnaire was sent to those who could not be reached by telephone.

Results The response rate was 49.6 percent. Compared to respondents, non-respondents were more likely to be teenagers (11 vs 3 percent), other than White race (12 vs 5 percent), and unmarried (26 vs 7 percent). No differences were found in the proportion of mothers living in rural counties or having professional occupations. The attendant category on the birth certificate agreed with the mother's response in only 30 percent of the cases (Table 1). Sixty-seven respondents said an unlicensed midwife attended their birth but only 12 birth certificates were correctly coded as such; 47 women said their birth attendant was a physician and 27 said the attendant was a licensed or certified nurse-midwife, for a combined total of 74 (36 percent) reporting that their birth attendant was actually licensed. Table 2 shows the attendants and birthplaces for the 1656 out-of-hospital births with attendant classifications changed to reflect the 206 survey responses. The majority of these births occurred at home. Of the 76 births classified as having an unlicensed midwife attendant, 75 were home births. Of the 1,030 home births, licensed midwives accounted for the TABLE 2-Out-of-Hospital Births by Type of Attendant and Place of Birth, Washington State, 1986

Out-of-Hospital Birthplace

Birth Attendant

Birth Center

Ucensed Physician Licensed Midwife Certified Nurse-Midwife Unlicensed Midwife Mother/Father Other Unknown Total

155 21 267 0 0 0 0 443

Other Medical





97 7 2 1 1 51 0 162

78 583 131 75 65 49 49 1030

8 7 0 0 2 3 1 21

338 618 400 76 68 106 50 1656

SOURCE: Washington State Vital Data, 1986, and 206 survey respondents

AJPH June 1990, Vol. 80, No. 6


% Unlicensed % Licensed % Nurse- % Ucensed % All Midwife Midwife Physician Other* Midwife



N: 583

N: 131

N: 78

N: 163

Matemal age

Unlicensed midwifery practice in Washington state.

We examined the role of unlicensed midwives in Washington State by questioning mothers of infants born out-of-hospital with an unlicensed person in at...
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